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Volume 9
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Qualitative Methods |
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In this Issue Qualitative Methods and Philosophies Hermeneutics and Nursing Research: History, Processes, and Exemplar Qualitative Methods and Applications
Qualitative Methods in Research
Other Original Research
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The Use of Phenomenological Inquiry by the Nurse Practitioner to Understand Clinical Problems Susan P. Porterfield, RN, PhD ABSTRACT Qualitative inquiry that seeks to understand human experiences can better serve patients that are living with a diagnosis of human papillomavirus (HPV). Phenomenology goes beyond just describing a disease but interprets the meaning of living with the disease. This approach provides the clinician with a full description of the experience by looking at it through an interpretation of a woman’s everyday experience. The nurse practitioner can use this information in counseling, assessing for physical and emotional needs, and relationship issues. Identifying these needs helps provide increased levels of care, empathy and respect, which is exactly what women want from their health care provider. The Use of Phenomenological Inquiry by the Nurse Practitioner to Understand Clinical Problems Nurse practitioners (NP) strive to provide holistic approach to the care of their clients. This means that the NP must not only have the knowledge and skills to assess, diagnose and treat medical illnesses or diseases, but must also have an understanding of the impact of that illness on clients, from a psychosocial perspective. Qualitative research designs provide the insights that assist the NP to better understand the experiences of clients who are living with a particular disease. As Munhall states, “qualitative research methods give voice to what nurses see, do, and experience.”1p36 Phenomenology provides a theoretical basis for qualitative inquiry that seeks to understand human experiences, and thus can provide the NP with relevant insights about how clients may be ‘living with’ their illness. Being diagnosed with HPV is not like having a cold or an infected wound. It has physical, social, and psychological ramifications. The experience of being diagnosed with HPV is not known or described in the literature; therefore phenomenological inquiry can be used to explore the experiences of women with HPV. Health care providers are key in providing non-judgmental care and accurate information. The purpose of this article is to further the NP’s understanding of phenomenological inquiry as a research design and how it may be utilized in providing evidenced based, holistic care to clients. It examines the historical and philosophical background of phenomenology as well as the process of implementing this methodology. Research exploring clients’ experience of living with a diagnosis of human papillomavirus (HPV) is used to illustrate how this methodology can be applied to a particular clinical problem. This research had IRB oversight and all women interviewed were fully informed and signed a consent form. Background Phenomenology has its roots in the human sciences with philosophers such as Husserl, Merleau-Ponty, Heidegger, and Gadamer. Husserl viewed phenomenology as a reasoned inquiry into the world of appearances, an attempt to glimpse the phenomenon as an experience or a descriptive approach. He proposed that the researcher process the information in a reductive fashion in which the core essence could be studied objectively through explicit descriptions.2,3 Bracketing is an attempt by the researcher to acknowledge prior knowledge or bias about a phenomenon. Setting aside prior knowledge or interpretive influences about a phenomenon allows a fresh impression about the phenomenon to be illuminated. This approach suspends assumptions about the phenomenon4 and may reintegrate the bracketed material into the analysis. The author of this article is a practicing nurse practitioner and very knowledgeable about HPV. Thus, as a researcher it was imperative to bracket out prior knowledge and biases regarding HPV when interacting with research participants as this could skew the thoughts and words of the subjects. Phenomenology is hearing what the subject is saying not only in words but feelings, thoughts, and spirit. Bracketing is also important to focus on what the subject is saying, not what the researcher believes the subject is saying or what the investigator wants them to say. When using this method the researcher also had to be mindful of truly listening to the clients without making assumptions about what the client was saying as a consequence of the researcher’s knowledge base regarding HPV. Merleau-Ponty looked at phenomenology as a study of “essences.” According to him, the “essence” is the nature of a thing, which makes something what it is. The phenomenological description is a focus on human lived experience in the world. Husserl referred to essences as the “whatness” of things instead of the “thatness” of things. Essences are related to the true meaning of something.1,2,5,6 An example of the essences or “whatness” in this study was feeling shame. The emotions of shame affected how these women felt about themselves, how they related to others, how they progressed through life, and even how they viewed the world. The concept of shame carried feelings of guilt, punishment, self-reflection, retribution for some unspoken event that aided in devaluing the participant’s self worth and self esteem. The first woman this researcher interviewed focused her emotions on the physical scars she received from removal of external warts. She didn’t come right out and say that it was a punishment for a “horrible act or misconduct” but her physical scars left some long lasting emotional scars:
Not all the women interviewed experienced physical scarring like Woman A but her experiences do reflect how traumatic her HPV infection was for her both physically and emotionally. This was the essence of her lived experience with HPV. One of Husserl’s students, Martin Heidegger, introduced hermeneutics into phenomenological study, which moved the lived experience from purely descriptive to more interpretative. Heidegger believed that pure description only limited the revelation of meaning in the lived experience.6,7 He felt that individuals live their life by experiencing it. Further, the specific meanings attributed to life experiences is hidden and requires interpretation to have a better understanding of existence. Heidegger focused on uncovering the hidden phenomena and emphasized the importance of an individual’s preconceptions. Therefore, hermeneutic phenomenology seeks to go beyond description in order to uncover those meanings that are not so apparent. In this research women used words and emotion to describe how each felt upon being told they had HPV. Words like “dirty,” “contaminated,” “disgusted,” “ashamed,” “embarrassed,” and “guilty” were all used. As the women spoke these words, they said them with such emotion there was no doubt about the depth of feelings they had and were experiencing.
Hermeneutic interpretation demands that the researcher is sensitive to the subtle undertones of language in conversation and to listen to the meaning.6 Gadamer looks at language as the medium for conversations. He noted that conversation has “a spirit of its own and that the language in which it is conducted bears its own truth within it.”8p383 A conversation is a process individuals go through to gain understanding and reflect essences. Such conversations are then interpreted by the research in part to develop a theory regarding a particular phenomenon. Munhall1 further elaborates on this concept by noting how important language and conversation are in phenomenology as a social interaction. Thus, conversation in research includes listening, keeping silent, and hearing the unknowing, thus allowing new ideas to take root within our beings. In using any method of phenomenological inquiry the researcher, then must be mindful of not only the words the client is using, but voice tone and affect changes. In the present study, such recognition was needed, as the clients described their lives or relationships prior to having the diagnosis of HPV and how their lives or relationships have changed. For instance, shame is a key factor in an individual’s inner being and conscience, and can result in low self-esteem, poor self-concept or body image, self-doubt, insecurity, and diminished self-confidence. Many of the women in this research portrayed an image of themselves as people that just didn’t get an STD. “Those people” were of loose morals and had many sexual partners. Woman M has external warts and at the beginning of the interview she had an air of confidence. However, during the interview as we spoke about her genital warts and her feelings she became less and less sure of herself, almost introverted. The following is how she described herself and others with HPV:
In summary, the goal of hermeneutic phenomenology is to uncover and reveal the meaning of the lived experience through a process of interpretation, rediscovery, and the analysis of linguistic meanings in language while setting aside ones own personal knowledge, biases and feelings.6,8 This approach was appropriate to explore the lived experiences of women who have been diagnosed with HPV for more than one-year. It provided the researcher with a full description of the experience by looking at it through an interpretation of a woman’s everyday experiences. The women were able to reflect on the lived experiences retrospectively or recollectively through their stories and their own eyes. The researcher was then able to engage in a reflective process, which further helped in uncovering meanings, which were both explicit and hidden. Using the hermeneutic phenomenological approach to the study of HPV involves gaining access to women’s experience in their world. Van Manen has set forth a model of phenomenology inquiry using eleven elements that are intended to increase one’s thoughtfulness and ability to capture the lived experience in a person’s “text” of life. An overview of Van Manen’s approach is outlined in Figure 1. The third column in the figure is examples from the HPV research. In his model, steps 1 through 3 are a way to orient to the phenomenon of interest and expose any pre-conceived notions about it. The first step is to orient to the phenomena. The second step is formulating the phenomenological question, and the third step is to explicate assumptions and preunderstandings of any personal bias to avoid drawing conclusions that do not reflect the data. Munhall1 refers to this as “decentering” the researcher by way of reflecting on her/his own beliefs, preconceptions, intuitions, motives, and biases and put on a face of “unknowing” when determining your experience that is part of your study. Steps 1-3, turning to the nature of the lived experience, was a search by the researcher to better understand what it is like to live with HPV after diagnosing a young woman with HPV. Remembering an encounter years before the initiation of this research, on the reaction of the woman after telling her she had HPV. The young woman was devastated and was unsure what to do next. It was apparent that more time and counseling needed to take place. As a nurse practitioner a greater appreciation for what women go through when the diagnosis of HPV is given was needed. The next phase is the process of exploring the phenomena, steps 4 and 5. Engaging in such activities as using personal experiences, or obtaining experiential descriptions as viewed by the study participants accomplished this exploration. The investigation was started through in depth conversations where women described thoughts, feeling, and concerns about their lived experiences. It also served as a vehicle to enhance and develop a conversational relationship with each woman. Conversation between two individuals creates interactive dialogue that provides stories and pictures that the individual is willing to share. The researcher listened to her and others to become heightened to what was being said by the participants. “We need … to be hearing the situated context of their being-in-the-world. …The thoughts, feeling, emotions, and questions are deeply embedded in the context of the participant’s life, or life-world.”1p148 The researcher accomplished this phase by audio taping the interviews and journaling before and after the interviews. Note taking during the interviews was minimal to avoid being distracted while listening to each woman’s story. The researcher transcribed all interviews personally, as this aided in data immersion. While the transcribing took place, one or two word notations aided in bringing back thoughts. Transcription took place within a week of each interview to facilitate note taking and journaling about each encounter. Additionally, the researcher chose to examine where this lived description fit into existing literature, the arts, or in life to facilitate grasping a deeper understanding of the nature of the phenomena. The purpose of the third phase, steps 6 and 7, of phenomenological reflection was to uncover themes from the woman’s experience and process them into essential themes of the research. Munhall1 describes this step as a contextual processing or a search for expression of meaning within the interviews with the participants. The researcher must dwell on the expression of meaning that is heard from an interview. This contemplation period is not measurable in time increments, but it takes as long as is necessary to use the language of the participants to illustrate the particular meaning that is portrayed. A mulling over, dwelling, and revisiting what the participant said are all intertwined “really” get to the expressed meaning.1 In this research, phenomenological reflection occurred first with listening to the subjects with total openness to their stories. Once the interviews were audiotaped and completed they were transcribed into text to allow for total immersion of the interview again, word-by-word, line-by-line. The third phase of this reflection occurred by insuring the written text reflected the spoken story, which took place by means of listening to the interview while reading the text to insure the transcription was accurate. Once data collection was complete, multiple rereadings (a minimum of 5 times) of the written text took place. The text was coded to identify themes that were emerging. This process of rereading is key in grasping the meaning of the women’s spoken words. The culmination of Van Manen’s method is to do the phenomenological writing. Writing the phenomenological narrative gives “voice to the actual language as it simultaneously interprets meaning from expressions used to describe the experience.”1p132 The writing style must communicate an understanding of the meaning of the phenomena by including all of the meanings, general and particular. The transformation of the spoken word into writing and interpretation should portray an accurate description of the meaning discovered. Munhall emphasizes the importance of the researcher not structuring the person’s story or having preconceived notions of what the women’s experiences mean.1 Quoting directly from the participants and using their own words from the interviews helps to clarify the points of interest and lend feeling about a specific experience.3,6 Once themes have emerged and descriptions of experiences have developed, another reading and re-reading of the transcriptions occurs to ensure that all the themes have been identified. Then outside readers, who are well versed in qualitative research, are also asked to read the transcript to validate interpretive descriptions. Readings, re-reading, writing and rewriting are all a part of the hermeneutic circle of understanding or interpretation. This process allows themes to evolve and aids in the formulation of an understanding of the feelings that have been generated by the lived experience.3,6,9 Once the reading and writing process is complete, then summarizing and answering the phenomenological question is accomplished.1 For this researcher, this phase of writing was similar to writing an outline for a paper. The researcher first wrote down all possible themes that evolved from the interviews. Once the twenty plus categories emerged it became apparent similar categories could be grouped into themes. The final outcome was five themes that captured the essence of what it was like to live with HPV. The five thematic groupings were identified as 1) the feelings embedded in the experience of having HPV; 2) the experience and fear of telling others; 3) finding out about the diagnosis and doing something about it; 4) transformation and behavior change which allow women to cope with the diagnosis; and 5) sharing experiences with others. The following is an example of Woman B’s overall experience with having HPV and reflects many of the themes:
She has had only three total partners and used condoms consistently with her first partner of three years. When they broke up, she was devastated and dated an individual twice and didn’t use protection either time. One year later she was diagnosed with HPV as a consequence of having a Pap test indicating she had a cervical intraepithelial neoplasia (CIN 3). She mentioned a number of times that she wondered where she got this HPV, as she has been fairly careful and protected except for her second sexual encounter. Application to NP Clinical Practice Taking a phenomenological approach can explicate the meaning of HPV for the client. The NP can use this information in counseling, assessing not only physical and emotional responses, but relationship difficulties as well. Identification of the needs of such women, via a phenomenological approach, may help providers to convey increased levels of care, empathy, or respect. Most of the participants in the current study felt that they had to be quite involved in their care in order to receive answers to their questions. They also depended on friends, or searched the Internet for the information they needed (which may not be supported by evidence base research). Feelings and emotions described by these women indicate a need for better strategies in caring for women living with HPV. The themes identified by women in the present study can be used to develop more sensitive and supportive protocols for current health care providers to implement in their practice. This research study confirmed earlier research by Anhang, Goodman, and Goldie10 who stated that the basic information desired by individuals with HPV is on transmission, prevention and detection, treatment, progression without treatment, and risk of cervical cancer. In regards to transmission, women really want to know that HPV is sexually transmitted. This sounds very basic but most of the women in this study did not know that HPV was sexually transmitted until weeks to years after the diagnosis. Secondly they want to know exactly how transmission can occur and what they can do to prevent or minimize the risks, including the risk of HIV/AIDS. Women in the Anhang study wanted to know how long and how often they could expect an outbreak. They wanted to know if HPV will always be present or if there might be a spontaneous resolution of the infection. They wanted to know what their chances of getting cancer were and whether the Pap smear and follow-up treatments really prevent the development of cancer.10 Such information will allow affected women to make rational health care decisions. Many of the women in this study, once they knew it was an STD and what to expect, were empowered to make choices about whether to have intercourse, whether to disclose to a potential partner, or whether to be aggressive in their treatment. But education is not enough. Women also need to be heard and allowed to express their feelings and reactions to having HPV. Summary The purpose of using phenomenological reflections is to grasp the meaning of lived experiences. As Van Manen noted, phenomenology is not a theory that explains or controls the world but “rather it offers us the possibility of plausible insights that bring us in more direct contact with the world.”6p9 It is a methodology that provides the NP with insights that can guide holistic approaches to not only this clinical problem but others as well. References
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